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Objectives: To establish the incidence and patterns of football injuries and associated consequences in daily life and labor loss, among public employees.

Design: Prospective cohort study.

Setting: Football tournament between public employees in Turkey.

Participants: A total of 1821 recreational players from 78 teams.

Main Outcome Measures: Injury rates (injuries per 1000 hours of football exposure) during tournament by age group, as well as prevalence, severity, and injury types were recorded. The data regarding the occurrence (eg, location, type, circumstances) and consequences (eg, absenteeism, medical treatment, labor loss) of injuries were collected.

Results: Of the 1821 football players registered for participation, 57% (n = 1038) were included in the study with the returned questionnaire forms. In total, 257 matches were played with a total exposure time of 5654 hours. A total of 218 injuries were recorded in 192 players (10.5%), resulting in a mean of 0.85 time-loss injuries per match (38.6 per 1000 hours). Severe injuries constituted 42.6% of all injuries, and 28.9% of all injuries caused the participants to be absent at least 1 day for the next working day. The total labor loss was 1196 days for all injuries. The rate of missing subsequent working day was significantly less for muscle injuries (P < 0.05).

Conclusions: The risk of injury in recreationalfootball players is relatively high causing significant labor loss. The results suggest that prevention programs should consider specific injury characteristics, as there is a greater incidence of muscle and anterior cruciate ligament injuries in this population.

From the Departments of *Sports Medicine; and

†Physical and Rehabilitation Medicine, Hacettepe University School of Medicine, Ankara, Turkey;

‡Department of Periodontology, Hacettepe University School of Dentistry, Ankara, Turkey;

§Medifit Sports Clinic, Ankara, Turkey; and

¶Departments of Orthopaedics and Traumatology, Hacettepe University School of Medicine, Ankara, Turkey.

INTRODUCTION

Football is the world's most popular team sport, and an estimate of more than 220 million players worldwide currently participate in organized football.1 Despite the low prevalence of licensed football players in Turkey compared with that in other European countries, playing football as a leisure activity is very common among all ages. However, along with its potential positive effects on players' metabolic, cardiovascular, and musculoskeletal parameters, football carries a substantial risk of injury.2 Although the popularity of football among older athletes is increasing, little is known about the training habits and injury histories of this group, all of which are key elements for the development of targeted injury prevention strategies.3

Football injuries in recreational players can result in both financial and time costs. Therefore, in this study, we observed football injuries during a tournament between public employees who may be described as “weekend warriors,” a term that describes people who engage in demanding recreational sports activities during weekends with only minimal or irregular physical activity during the week.4 The aim of the study was to establish the incidence and patterns of injuries and the associated consequences on daily life and labor loss, for public employees playing football as “weekend warriors.” To the best of our knowledge, no previous study has investigated the incidence and characteristics of football injuries in such a population, and recreational players have not previously been investigated in any prospective injury study.5

METHODS

Study Design, and Participants

A prospective cohort study conducted during a football tournament between public employees organized by the Provincial Directorate of Youth Services and Sports of Ankara in 2014. A total of 78 public institutions participated in the tournament, including ministry offices, directorate generals, universities, and government offices. Before the tournament, each institution was requested to announce a squad of 25 players, wherein only 6 were allowed to be younger than 30 years; the tournament rules made it clear that only 3 of these players younger than 30 years were allowed in the starting 18 players for each game. In total, 1821 male public employees were listed in the 78-team squad. The mean age was 35.2 years [range, 20-56 years; standard deviation (SD): 7.7], with the greatest numbers of players in the 30 to 34 and 35 to 39 age groups (32.4% and 22.9%, respectively).

During the draws for the tournament, authorized persons or coaches from all the teams were informed about the study. A questionnaire was developed that took into account the recent consensus statement on football injury definitions and data collection procedures.6 Questions covered age, weight, height, recent and previous football activity levels, playing position, dominant leg, warming-up/cooling-down behaviors, and any injury history. Of the 1821 football players registered for participation, a cohort of 1038 (57%) was included in the study, all giving their informed consent with the returned questionnaire forms. Informed consent was obtained from all subjects, and the study was approved by the local ethics committee of Hacettepe University Human Ethics Committee (Decision number: GO 14/306-18).

Injury Registration and Exposure

All teams were asked to nominate an authorized person (a team adviser) for the study, preferably the coach or team manager, to report any injuries during the matches that caused a player to be unable to finish the game, attend his job on the next working day, or play the next game in the tournament. Each team adviser was called on their mobile phone within 48 hours after the end of each match and asked about any injuries.

All competitive matches were played on regular-sized artificial turf pitches for 60 minutes under the management of referees appointed by the Turkish Football Federation Ankara Referee Committee (TFFARC). Exposure time was calculated on the basis of 22 players and a 60-minute match for all games in the tournament. A total of 257 matches were played with a total exposure time of 5654 hours. Injuries and exposure hours were defined and recorded in accordance with the consensus statement on injury definitions and data collection procedures in football studies.6 The incidence of injury per 1000 match-hours was calculated using the formula: (number of injuries × 1000 match-hours)/[(minutes of exposure/60) × N players exposed]. The number of players exposed was 22 for calculation of incidence in the different match periods, and minutes of additional time were not taken into account.7

RESULTS

Anthropometric and other baseline data of the participating players are presented in Tables 1 and 2. The participants' mean time spent working at their institutions was 9.4 years (range, 1-31 years; SD: 6.9).

More than half of the participants declared that they played football at a licensed level. For these participants, the mean age at which they received their football license from the National Football Federation was 15.2 years (range, 7-26 years; SD: 3.1), and the mean length of time they had played licensed football was 8.6 years (range, 1-32 years; SD: 6.5). Most of the participants (80.4%) reported that they play football for an hour at least once a week as leisure time activity.

Almost half (48.3%, n = 501) of the participants had previously experienced at least 1 musculoskeletal injury related to football. Bone fractures were the most commonly reported injury type, experienced by 170 participants (16.4%), and the most common fracture sites were the upper extremity bones (forearm and wrist, 6.6%), lower extremity bones (foot, ankle, tibia, and fibula, 4.8%), and nose (3%). Previous muscle injury was reported by 167 participants (16%), most commonly located in the lower extremity muscles (calf, 51; hamstring, 48; adductor group, 43). Previous injury history in subjects who played football as a licensed level before was higher than that in unlicensed ones (54.2% vs 29.3%, respectively). In addition, the level of profession was related with previous injury frequency compared with amateur players or youth level (P < 0.05). Football injuries resulted in 228 participants (22%) being absent the working day, and 86 (8.3%) had a history of surgical operations because of football injury, almost half of which were arthroscopic meniscus repair (2.2%) or anterior cruciate ligament (ACL) reconstruction (1.7%).

Frequency and Nature of Injuries (Injury Type and Location)

During the 257 matches of the tournament, 218 injuries were reported in 192 players (10.5%), resulting in a mean of 0.85 time-loss injuries per match. This was equivalent to 38.56 injuries/1000 match-hours. The mean age of the injured players was 36.2 years (range, 22-54 years; SD: 7.1). Anthropometric and other baseline data of the players who sustained injury during the tournament are presented in Table 3. The frequency of traumatic injuries (49.1%) was almost the same for atraumatic injuries (50.9%), and both sides of the body were almost equally affected by extremity injuries. The locations and types of injuries are presented in Tables 4 and 5. Nearly 6 of 10 injured players (n = 132, 60.5%) reported a previous football injury, with 32.1% experiencing the same injury as before. Of the 87 players who had muscle strain during the tournament, 39 had previously experienced the same injury, with the hamstring (24 of 44 injuries) and quadriceps (8 of 16 injuries) being the most common muscles for recurrent injuries. The injuries most commonly occurred after half-time, between 31 and 45 minutes.

The injury severity was set based on the number of days the player was absent from their subsequent training sessions or matches (slight, 0-3 days to full return; minor, 4-7 days; moderate, 8-28 days; and severe, ≥28 days; Table 6). The median time off sport because of injury was 17.5 days (range, 1-405 days; SD: 80.3). Sixty-three of these injuries (28.9%) caused participants to be absent at least 1 day for next working day. The total labor loss was 1196 days for all injuries with a median time of 10 days (range, 1-90 days; SD: 20.0, mean: 19.0 days). Eighteen injured players were unable to work for more than 1 month. Seventeen of the injured players had casts to immobilize a joint or extremity. Nineteen patients were referred for surgery, but 7 of them (6 ACL ruptures and a zygomatic bone fracture) were denied surgery after 2 years of follow-up, leaving 12 patients who underwent surgery (7 ACL ruptures, 2 medial malleolus fractures, one Achilles tendon rupture, one first metacarpus fracture, and one acromioclavicular separation). The rate of playing the subsequent game in contusion injuries was significantly higher (41.9%) than in fractures (4.8%) and ligament injuries (11.9%). The players who had fractures during the tournament returned to sports after a significantly longer time than those who had other injury types (P < 0.05). Of 21 players with fractures (81.0%) during tournament, 17 returned to play after 1 month. However, no relationship was detected between the injured muscle and time taken to return to sports (P > 0.183). Muscle (7.6%) and contusion injuries (19.4%) caused significantly less labor loss compared with fractures (66.7%) and ligament injuries (61.9%).

DISCUSSION

The principal finding of this study was that playing football may cause significant labor loss in recreational players. Injuries during the tournament led to 1196 days of labor loss, accounting for 211.5 days off per 1000 match hours. In addition, 22% of the participants reported previous football-related injury that caused them to be unable to attend work. The rate of missing a subsequent working day was significantly less for muscle and contusion injuries.

Several previous studies have reported football injuries, especially among professional elite and amateur players. A few studies investigated the incidence of injuries and the characteristics of football play among Masters players, but information regarding injuries in recreational players and the effect of these on labor loss is scarce.3,5 Newsham-West et al3 investigated the training habits and injuries in football players participating in a national Masters tournament. A limitation in the design of this study was that this was cross-sectional and did not include collection of exposure data. However, the incidence rate was estimated at 14 injuries per 1000 match hours if they assume an exposure of 90 match minutes per player during a 20-week competition season for 199 participants. Their population differed from our study group with older age (44.0 vs 34.8 years), longer history of football playing, and the number of players who had played for a club in an organized competition at a professional level (53.8% vs 6.8%). Another study documented the injuries and characteristics of 18 veteran football teams with 265 players for more than 1 season.5 The incidence of training injuries was reported to be significantly lower than that of match injuries (4.5 vs 24.7 per 1000 hours). The median lost time because of an injury was 17 days for the veteran players, which was almost equal with that for participants in this study. However, the mean time to sports for all injuries was longer at 49.3 days in our group. This longer return time was probably because of the higher incidence of ACL injuries in our study group. In addition, contact/traumatic injuries were more common in our study group (49.1% vs 35.2%); therefore, fractures were more common (9.6% vs 4.5%). In agreement with reported studies for other populations, most injuries occurred in the lower extremities (82.1%).3,8 In addition, muscle strains, especially hamstring injuries, were the most frequent injury with almost the same incidence in veteran players. However, the overall percentage of hamstring injuries in our study was higher than that in a previous study investigating younger male football players.9 The incidence of hamstring injuries in our group was 7.8 per 1000 match hours. No information was disseminated regarding the training sessions of our group, but less training time and unstructured training methods is well known to result in insufficient hamstring strength, which is associated with a higher hamstring injury risk in recreationalfootball players.10

Numerous studies have emphasized the facilitating role of similar previous injuries for the recurrence of injuries at the same site.11,12 The players who suffered a muscle injury during the tournament reported significantly more previous muscle injuries (44.8%, P < 0.05), as expected. The rate of recurrent hamstring injuries in our group was slightly higher (54.5%) than that in previous reports.5,13,14 Compared with other injury types, muscle injuries were seen more frequently in older subjects (37.9%). In contrast, the timing of the injury during the game was not statistically related with injury type indicating that muscle injuries were not associated with fatigue.

Age, sex, skill levels of football players, and lower training/match ratio may affect the incidence of match injury.14,15 However, no differences were found between the participants who completed the questionnaire forms and injured subjects on age, body mass index, educational level, preparticipation medical examination, playing position, dominant leg, boot type, warming-up/cooling-down behaviors, and smoking habits. Injury history in subjects who played football as a licensed professional was significantly higher than those in amateur and unlicensed players. The subjects who played football at a licensed professional reported more injury than those unlicensed during the tournament. Strikers were significantly more prone to sustain injury than goalkeepers and defenders.

Starting with the 1998, The Fédération Internationale de Football Association (FIFA) World Cup, FIFA has surveyed match injuries for all their subsequent tournaments and football competitions in the Olympic Games. Recently, the time-loss injury incidence in the 2014 FIFA World Cup was reported to be 29.3 per 1000 hours, equivalent to 1.68 injuries per game.8 The incidence of time-loss injuries in our group was 38.6 per 1000 match hours. Injury incidence is known to be higher in tournaments that take place over a shorter period than over a play season. This suggests that increased match play (exposure time) over a shorter period may also be an important risk factor for football injuries. In addition to age and skill level in general, recreational players in our study differed in several aspects from professional players, such as physical condition, training history, including preventive training; and the physiological demands of training and match play. These underlying factors may contribute to a higher injury incidence for recreationalfootball players. Structured warm-up is well known to be linked to a reduced injury risk, and insufficient warm-up might possibly cause football injuries.16 Despite the reported high rate of warm-up behavior among our participants, we observed that a regular warm-up is almost nonexistent in such groups of football players. In addition, players were more highly motivated and, therefore, more aggressive when playing matches, as they were representing their institutions.

In accordance with our findings, almost two thirds of injuries affected the lower extremity during the 2014 FIFA World Cup, and the most frequent diagnosis was thigh strain. However, one of the most frequently affected parts of the body in the aforementioned study was reported to be the head and neck (18.3%). We reported a lower incidence of head injuries (4.6%), including concussion, laceration, and fractures, than that in the World Cup data since 1998. Severe injuries that resulted in player absence from sports for at least 28 days in our group were significantly higher than that in the World Cup data (42.6% vs 7.7%). This is in accordance with the study of van Beijsterveldt et al17 that compares the injury incidence of amateur and professional Dutch players, showing that professional players had a significantly higher risk for minimal injuries and a significantly lower risk for moderate or severe injuries than among amateur players. They claimed that more experienced players acquire skills relevant to avoid injury-prone actions. Although the mean number of time-loss injuries per match in our study was lower than that in the World Cup data (0.85 vs 0.97), this was probably due to the shorter match duration (60 vs 90 minutes) in the present tournament.

Although the referees were appointed by the TFFARC, resulting in a higher standard than that in recreational players, half of the traumatic injuries were noted to be caused by opponents' foul play, and almost one-third of these incidents were not penalized by the referee with a free kick, and only 7 players were booked. Therefore, a higher level of referees allowing foul play by adjusting rules at the amateur or semiprofessional level should be considered.

This study has some limitations. This study focused on acute match injuries; thus, training injuries and illness/diseases were not registered. Our results lack the regular training habits of the participants. Exposure time was calculated based on 22 players and a 60-minute match for all games in the tournament. A more precise method would take account of the extra time in the games and of red cards that cause exposure time loss. However, the response rate of this study was 100%. Because all the team advisers were called on their mobile phones within 48 hours of each match and asked about the injuries, we consider that no values regarding injuries were missing. In addition, all injured players were directed to our clinic for diagnosis and treatment. Furthermore, the follow-up of each injured player until his return to full training or match play was under our control.

CONCLUSIONS

This study is the first to report injury incidence during a tournament involving recreationalfootball players. The preliminary data from this study suggest that recreationalfootball carries a relatively high risk for injury that causes serious sick leave. Playing football is accompanied by exposure to injury, and knowledge on the epidemiology of football injuries could allow sports medicine professionals, such as physicians and physiotherapists, to direct their work in developing specific preventive programs. It should be noted that prevention programs for recreational players should consider specific injury characteristics, with more muscle and ACL injuries in this population.